Case Manager Role Definitions: Do They Make an Organizational Impact?

The role and contribution of nurses to patient flow management in acute hospitals: A systematic review of mixed methods studies

BACKGROUND

Increased overcrowding in the emergency department is a potential threat to the quality and safety of patient care. Innovative ways are needed to explore overcrowding, the variables affecting patient flow and interventions necessary for future flow improvement.

AIMS AND OBJECTIVES

The aim of this review is to explore nurses' role(s) and their contribution to maintaining patient flow in acute hospitals through emergency departments.

METHODOLOGY

A systematic review of mixed studies (qualitative, quantitative and mixed-method) using narrative synthesis was undertaken. Five major databases-PubMed, CINHAL, BNI, ASSIA and SCOPUS-were searched to identify appropriate primary and secondary studies. Selected studies were critically appraised with a modified CASP tool. Data extraction and analysis was undertaken using narrative synthesis.

RESULTS

In total, 34 articles (31 primary studies and three systematic reviews) met the inclusion criteria. This systematic review is informed by studies from several countries, including the UK, US, Australia, Canada, and the Netherlands. The qualitative arm of this review explored both the role and function of nurses, as well as their experiences and perspectives of the patient flow process, while the quantitative arm investigated nurses' contribution to patient flow in terms of length of stay (LOS), triage time, and other associated performance data.

FINDINGS

Nurses' contribution to patient flow spanned their operational, strategic, and expanded roles. Strategic and expanded nursing roles offered the possibility of reducing LOS, triage time, and ED crowding in addition to improving the experience of patients and staff. Nurses in operational roles deployed experiential knowledge pertaining to several invisible aspects of patient flow challenges thereby facilitating decision-making for strategic flow improvement. The experiential knowledge and skills of these nursing roles are central to the success of flow-related interventions. However, the effects of emotional labour (e.g. conflicts, frustrations) of patient flow processes on nurses are significant and may have unaccounted for transaction costs and consequences that need acknowledging in order to be addressed by managers and policy makers.

CONCLUSIONS AND RECOMMENDATIONS

Policy-makers and senior managers need to capitalise on nurses' experiential knowledge and skills to enhance the strategic design and development of flow management in acute hospitals. Recommendations from this review have potential to deploy those skills and knowledge in flow improvement.

Factors Affecting Length of Stay for Observation Patients

Objectives

The objective of this study was to determine whether the addition of a case manager and a physician advisor to the observation unit would decrease the length of stay (LOS) of observation patients.

Study design

This retrospective, observational study for observation patients was conducted in 2017.

Methods

At a tertiary-care, medium-sized, urban, community hospital, the LOS for all observation patients in 2017 (2, 981 clinical decision unit [CDU] patients and 1,248 non-cohort patients) was studied. Interventions studied were the addition of unit-based case manager and physician advisor to observation patient treatment teams.

Results

Patients assigned to the CDU had a shorter LOS than scattered patients, p < 0.0005. After the data was controlled for changes in LOS on inpatients using analysis of covariance (ANCOVA), none of the interventions resulted in statistically significant effects on LOS for CDU or scattered patients. Season, day of the week, the month of the year, and the presence of residents/medical students did not have any effect on LOS. Patients arriving at night had significantly shorter LOS than those arriving during the day or evening, p = 0.035 and p = 0.029, respectively.

Conclusions

Placing observation patients in a single unit is effective for decreasing LOS. The addition of case managers or physician advisors may not be an effective strategy to address the LOS. The presence of trainees does not hinder patient flow.

Using a shared governance structure to evaluate the implementation of a new model of care: the shared experience of a performance improvement committee

Sustaining change in the behaviors and habits of experienced practicing nurses can be frustrating and daunting, even when changes are based on evidence. Partnering with an active shared governance structure to communicate change and elicit feedback is an established method to foster partnership, equity, accountability, and ownership. Few recent exemplars in the literature link shared governance, change management, and evidence-based practice to transitions in care models. This article describes an innovative staff-driven approach used by nurses in a shared governance performance improvement committee to use evidence-based practice in determining the best methods to evaluate the implementation of a new model of care.